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Population Health Management is in its early stages of maturity, suffering from inconsistent definitions and understanding, and is overhyped by vendors and ill-defined by the industry. And yet, many systems are moving forward in innovative pioneering ways to address this growing trend. In this session, you will hear from two very different, successful health systems: a physician-led group and a large integrated delivery system. They will share their best practices, learnings, and different approaches to population health management.
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#HASummit14
Sreekanth Chaguturu, MD Vice President for Population Health Management, Partners HealthCare
Session #21 Key Principles and Approaches to PHM
Dr. Sreekanth Chaguturu is Vice President for Population Health Management at Partners HealthCare. He provides clinical oversight to population health management clinical programs, assists in management of clinical relationships for risk contracts with commercial and government payers, as well as oversight for Partners’ self-insured health plan. In these roles, he leads the assessment and development of information technology and analytic solutions to support population health programs.Dr. Chaguturu is also an Instructor in Internal Medicine at the Harvard Medical School and an attending physician at Massachusetts General Hospital.
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Greg Spencer, MD Chief Medical & Chief Medical Information Officer, Crystal Run Healthcare
Dr. Greg Spencer is the Chief Medical Officer and Chief Clinical Information Officer at Crystal Run Healthcare. He graduated from the Medical College of Wisconsin and completed residency training in Internal Medicine at Wilford Hall US Air Force Medical Center in San Antonio, TX, where he was chief resident and assistant director of the Internal Medicine Residency program and attained the rank of major. He is board certified in Internal Medicine and a Fellow of the American College of Physicians.
Dr. David A. Burton is the former Executive Chairman and CEO of Health Catalyst, and currently serves as a Senior Vice President, future product strategy. Before his first retirement, Dr. Burton served in a variety of executive positions in his 23-year career at Intermountain Healthcare, including founding Intermountain’s managed care plans and serving as a Senior Vice President and member of the Executive Committee. He holds an MD from Columbia University, did residency training in internal medicine at Massachusetts General Hospital and was board certified in Emergency Medicine.
David A. Burton, MD Former Chairman and CEO, Health Catalyst, Former Senior Executive, Intermountain Healthcare
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Poll Questions (1-3)Does your organization sponsor or participate in a population health management/shared accountability initiative (e.g., ACO or commercial)a. Yesb. Noc. Not sured. Not applicable
What percent of your patients are covered by your organization’s population health/shared accountability initiative?a) Less than 5%b) 5-10%c) More than 10%d) No ideae) Not applicable
In your opinion, how successful has your organization’s population health/shared accountability initiative been to date?f) Not at all successfulg) Slightly successfulh) Somewhat successfuli) Successfulj) Very successfulk) Unsure or not applicable
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Gregory Spencer MD FACPChief Medical Officer
Crystal Run Healthcare
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Our Approach
• Triple Aim as an organizational outline
Better care, better health, lower cost
• Analytics: multisource, scalable platform
• Provider involvement
• Care managers, CARETEAM, Telehealth
• Monitor the data
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NY Healthcare Environment
• Massive consolidation and mergers
• Bankruptcies
• Larger systems and groups
• Optum
• Venture capital
• Mostly unmanaged
• Urgent care centers and retail medicine
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Crystal Run Healthcare
Physician owned MSG in NY State, founded 1996
300+ providers, 20 locations
Joint Venture ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology
Early adopter EHR (NextGen®) 1999
Accredited by Joint Commission 2006
Level 3 NCQA PCMH Recognition 2009, 2012
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Crystal Run Healthcare ACO
• Single entity ACO
• April 2012: MSSP participant
• December 2012: NCQA ACO Accreditation
• 35,000 commercial lives at risk
• MSSP
11,000 attributed beneficiaries
82% primary care services within ACO
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Business Intelligence Past
• Initially BI = business only, reports
• Quality, safety measures and clinical performance later
• Basic tools: SQL, SSRS, Excel
• Manual and time consuming
• Report generation > analysis
• Lack of scalability and extensibility
• Mostly tabular / numeric
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Dashboards
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Business Intelligence Now
• Central EDW- many sources, fewer joins
• Scalable
• More analysis, less reporting
• Self-service and drill down
• Consume and deliver information
• Visual
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Basic System Needs
• Common integrative platform
Pull together disparate data
• Cost: claims where available, internal costs
• A way to implement change
• “Leakage” and network
Where are patients going, are needs being met?
• Lean
Waste reduction, everywhere
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How we chose our EDW
• Our bias: controlled by us
• Avoiding “black boxes”
• Prior healthcare experience
• Modern technology
• Established track record
• Teach us how to fish
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Crystal Run EDW Roadmap
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Improving the patient experience
• Web Portal
• Care Managers
• Shadow Coaching
• Choosing Wisely
• Practicing Excellence
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Variation Reduction
• Specialty and division sponsored
Best practice review
Buy-in at the physician level
• Provider projects
Innovation contest
• National: Choosing Wisely
• Improved access - backfill and market share
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Variation Reduction
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Variation Reduction Improves Access
• 41,823 fewer visits
• 30,206 more patients
• “Created” 12 physicians
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Reducing Pharmaceutical CostsPEG Filgrastrim cost per patient before and after breast cancer pathway
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Total cost difference(equalized as cost per patient treated)
2012 pre-pathway
791 patients
$595,920
2013 post-pathway
817 patients
$368,160
TOTAL COST SAVINGS $227, 760
PEG-filgrastim use in Breast cancer patients
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Summary
• Triple Aim, core values as a guide
• Unified analytics platform that integrates disparate systems is required
• Quality, safety and performance programs that are tracked
• Physician involvement, variation reduction
• Patient experience
• Leakage, where and why
• Systematically find and reduce waste
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Sreekanth Chagaturu, MDMedical Director for Population Health Management
Partners HealthCare
Division of Population Health Management
September, 2014
Chapter 2: Innovations in Population Health Management
Sree Chaguturu, MDVice President, Population Health Management, Partners Health Care
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My goals for today
• Describe Massachusetts health reform efforts
• Provide overview of Partners Healthcare • Review select programs
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Patient Protection and Affordable Care Act
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My fair city…
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Chapter 58 of the Acts of 2006: An Act Providing Access to Affordable, Quality, Accountable Health Care
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Increasing health care spend in Mass crowded out all other areas
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Health care reform part two
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Who We Are: Partners HealthCare
• Massachusetts General Hospital• Brigham and Women’s HospitalTeaching Hospitals
• Newton Wellesley Hospital• North Shore Medical Center • Martha’s Vineyard and Nantucket Hospitals
Community Hospitals
• Spaulding Rehabilitation NetworkNon Acute Care
• McLean HospitalMental Health Care
• Partners Community Health Care• Community Health Centers
Community Provider Network
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Towns With PCHI Primary Care Care Physician Practices
MGH
McLean
Salem & Shaughnessy Kaplan
Union
BWHFaulkner
Newton-Wellesley
Spaulding
Partners Acute Hospitals
Partners Specialty Hospitals
RHCI
Partners Home Care Branches
Partners HealthCare across eastern Massachusetts
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Our Employees• ~60K employees – the largest non-government employer in the
state• ~13K are MDs, RNs and direct care givers• ~5K are primarily involved in research
Our Patients• ~1.6M ambulatory visits• ~168K discharges• ~4K licensed beds• ~$205M investment in community benefits
Teaching• 28 residency programs provide training to ~1,400 residents• ~$ 167M investment in teaching
Clinical Research• ~$1.6B in academic/research revenue • ~2,800 paid researchers (MDs & PhDs)
What we do
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Partners currently covers over 500,000 lives in an accountable care contract
Medicare Commercial Self Insured
•Example: Pioneer ACO
•Covered lives: ~74k
•Example: Alternative Quality Contract
•Covered lives: ~350K
•Example: Partners Plus
•Covered lives: ~100k
Medicaid
•Example: NHP
•Covered lives: ~30k
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Partners is implementing over a dozen PHM Programs
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Primary Care •Patient Centered Medical Home (PCMH) •High risk care management (palliative care) •Mental health integration •Virtual visits
Specialty Care •Active referral management (eConsults/curbsides)•Virtual visits• Procedural decision support (appropriateness)•Patient reported outcomes •Episodes of care (bundles)
Care Continuum •SNF care improvement (network/waiver/SNFist)•Home care innovation (mobile observation/telemonitoring) •Urgent care
Patient Engagement •Shared decision making•Customized decision aids and educational materials
Infrastructure •Single EHR platform with advanced decision support •Data warehouse, analytics, performance metrics
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And why these programs?
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Primary Care •Patient Centered Medical Home (PCMH) •High risk care management (palliative care) •Mental health integration •Virtual visits
Specialty Care •Active referral management (eConsults/curbsides)•Virtual visits• Procedural decision support (appropriateness)•Patient reported outcomes •Episodes of care (bundles)
Care Continuum •SNF care improvement (network/waiver/SNFist)•Home care innovation (mobile observation/telemonitoring) •Urgent care
Patient Engagement •Shared decision making•Customized decision aids and educational materials
Infrastructure •Single EHR platform with advanced decision support •Data warehouse, analytics, performance metrics
Develop team based care
Demonstrate value in procedures
Reduce post acute variation
Empower patients in their care
Information -> Insight -> Action
Promote Medical Neighborhood
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Successful ACOs will use predictive analytics to launch a high risk care management program
High risk patients - those at risk of being high cost
Not Chronically
Ill, Medically Complex
Medically Complex
Primary Care
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Chronic Condition
Mental Health Disorder
Patients with a mental health disorder have 40% higher chronic condition costs
Significant opportunity in integrating mental health services into primary care
Mental Health
Primary Care
Better identify patients Increased screening
Better triage of patients Phone access line with referral support
Better use of protocolsIMPACT for depression, SBIRT for substance abuse
Better self-management Online patient-directed therapy (iCBT)
Better access to services
Better tracking outcomes IT tools tracking longtitudinal progress, Patient reported outcomes measurement
Examples [Current and Future]Key Elements
Embedded mental health resources, consulting psychiatrist
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Primary Care
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Virtual visits allow us to connect to patients in more convenient ways (and avoids unnecessary office visits)
Asynchronous
Models that deliver care to people without requiring real-time interaction
Synchronous
Models that allow people and providers to connect in real time
Specialty Care
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Patient Reported Outcome Measures are outcomes that matter (and demonstrates value to market)
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Direct collection of information from patients regarding symptoms, functional status, and mental health.
Func
tiona
l Sta
tus
time
Surgery
Tier 1: Health status achieved
Tier 2: Process of Recovery
Tier 3: Sustainability of Recovery
Specialty Care
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We can improve a patient’s surgical journey(and avoid unnecessary or unwanted surgeries)
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Patient with a
Surgical
Problem
Assess Appropriateness
Criteria
Schedule OR
Procedure Recovery Physician Encounter
Possible Need for
Procedure
Shared Decision Making
Pre-Procedure
Testing
Short-term Outcome Measures
Long-termOutcome Measures
Personalized Risk
(Consent Form)
Informed Consent
PROs Survey(s)
PROMsPrOE (Procedure Decision Support)PROMs
Milford CE, Hutter MM, Lillemoe KD, Ferris TG. (2014). Optimizing appropriate use of procedures in an era of payment reform. Annals of Surgery 206(2): 202-204
Specialty Care
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Nationally, these 7 procedures account for $56.6 billion, or 55% of the total costs of the 20 most
costly procedures in the US:• Spine fusion• Spine laminectomy• Knee arthroplasty• Hip replacement• PCI• CABG• Heart valve repair
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We target the most costly procedures
Specialty Care
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Clinical
Office
MGH Admit-ting
Payer
Patient visits surgeon and lumbar laminectomy is indicated
Surgeon schedules procedure
Admin knows procedure requires PA?
Admin faxes form to admitting
Admitting checks for form
Admitting submits PA
PA reviewed by third party
Decision submitted to Admitting Manually
appeal claim
Admitting enters auth # in PATCOM
Patient undergoes procedure
Admitting checks for form
Admitting calls clinic to work through PA form
No
Yes
Denied
PrOE completed
PrOE PA form sent to Admitting
PA is granted without third party review
Authorization submitted to Admitting
Potential savings:• Current process: o 4-5% denial rate, o <1% ultimately denied
• PrOE process:o Produces same result (<1%
denial rate) o Reduces administrative
burden
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Ultimately, we have created a more efficient prior authorization
Specialty Care
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We can do a better job in helping our patients understand their healthcare encounters….
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Redundant, inconsistent, and perishable educationalencounters in healthcare
Problem
Reduced provider productivity and patient satisfaction
Outcome
Patient Eng.
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… by providing a non-perishable, personalized solution to patient education
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Redundant, inconsistent, and perishable educationalencounters in healthcare
ProblemImproved provider productivity and patient satisfaction
Outcome
Provider-generated, video-based educationprescribed to patients before, during, and afterclinical encounters.
Solution
Patient Eng.
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We believe personalized non-perishable education will improve outcomes and satisfaction
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• Series of short, single-topic videos featuring a patient's own healthcare provider.
• Improve provider efficiency, increase patient engagement, and improve clinical outcomes
Patient Eng.
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Thank you! Thoughts or questions?
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MGH NY Cardiac Database0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Rarely Appropriate
Maybe Appro-priate
Appropriate
Appropriateness Scores for Diagnostic Catheterization by Month (all AUC Indications)
Aug Sept Oct Nov Dec0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
*Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741
n=156 n=8986
Median hospital-level inappropriateness rate is 28.5%*
Appropriateness Scores for Diagnostic Catheterization for Suspected CAD at MGH vs. NY
Cardiac Database*
Appropriateness Results: Diagnostic Cath
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Appropriateness Data Repository
Procedure Scheduling
PrOE Appropriateness tool
Public Reporting
PCI, CABG, Vascular,
Harris Joint
Internal Performance Dashboards
Billing and Prior Authorization
RPM, RPDR, CDR, EMPI
Pre-populated data fields (NLP search)
INPUTS OUTPUTS
Personalized consent formExisting
registries
LMR, OnCall
Data storage
EMR
Appropriateness Indications & Decision support
Measurement & analysis of appropriateness and outcomes
inform guidelines and indications in real-time
Data passback to registries (Web service)
Copy of appropriateness results placed in LMR and CDR
EHR note created
PrOE: Inputs and outputs
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Analytic Insights
AQuestions &
Answers
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Session Feedback Survey
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1. On a scale of 1-5, how satisfied were you overall with this session?1) Not at all satisfied2) Somewhat satisfied3) Moderately satisfied4) Very satisfied5) Extremely satisfied
3. On a scale of 1-5, what level of interest would you have for additional, continued learning on this topic (articles, webinars, collaboration, training)?
1) No interest2) Some interest3) Moderate interest4) Very interested5) Extremely interested
2. What feedback or suggestions do you have?
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Upcoming Keynote Sessions2:20 PM – 3:10 PM
23. Predictive and Suggestive AnalyticsDale SandersSenior Vice President, Health Catalyst
3:25 PM – 4:25 PM
24. From The Heart: Healthcare Transformation From India To The Cayman IslandsDale SandersSenior Vice President, Health CatalystChandy Abraham, MDChief Executive Officer, Director of Medical Services Health City, Cayman IslandsGene Thompson, Health City Director, Director of Thompson Development, Ltd.
4:15 PM – 4:45 PM
25. Closing KeynoteDan Burton, Chief Executive Officer, Health Catalyst
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Location
Main Ballroom